NURS 680B Advanced Health/Physical Assessment Week 8 Assignment Comprehensive Physical Exam (Shadow Health)
NURS 680B Advanced Health/Physical Assessment Week 8 Assignment Comprehensive Physical Exam (Shadow Health)
NURS 680B Advanced Health/Physical Assessment
Week 8 Assignment
Comprehensive Physical Exam (Shadow Health)
This Comprehensive Assessment (Capstone) assignment provides you the opportunity to plan and conduct a full comprehensive health assessment on a patient in a single clinic visit. You will move through both the subjective and objective assessment in a head to toe order.
In this final comprehensive Shadow Health assignment, you will:
Interview your digital patient, Tina Jones within Shadow Health. She will be presenting for a pre-employment physical. You will be conducting a comprehensive assessment which includes interviewing (complete subjective history) and an examination of the patient (complete objective examination).
This assignment will take you approximately 2 hours to complete.
In order to use the voice-to-text functionality in Shadow Health (not required) you will need to use the latest Chrome web browser.
You are welcome to revisit your Shadow Health assignment as many times as you like up until the assignment due date deadline; to leave the assignment open, do not click on “Submit” until you are satisfied with your performance.
If you accidentally submit your assignment and would like to revisit it, contact the Shadow Health support team (see below). The assignment cannot be reopened after the assignment due date.
Complete self-reflection prompts to help you think more deeply about your performance in the assignment. Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning process. The more detail and depth you provide in your responses, the more you will benefit from this activity.
Read Also: NURS 680B Week 5 Assignment Comprehensive Health Assessment
This assignment is to be completed in Shadow Health. Even though your activity and responses will be recorded in Shadow Health, in Blackboard click on the assignment name above, select the Write Submission option, type the word “Confirmed” and then click Submit to save.
The Tina Jones comprehensive and physical assessment polished my physical examination skills of examining the various body systems. I developed skills in interviewing a patient on their current symptoms, past medical history, and lifestyle practices that will guide in developing a management plan. I learned that every question asked to a patient should have a rationale and should help in coming up with a definitive diagnosis and ruling out the differentials. I also learned new techniques on examining the neurological system when assessing if a patient has developed symptoms of nephropathy, which is a common complication of diabetes. The examination techniques for neuropathy included testing graphesthesia, stereognosis, position sense, and testing for sensations with monofilament, light touch, dull pain, and sharp pain. I plan to integrate the assessment and physical examination skills in the future when assessing patients to rule out or confirming a diagnosis. I will also apply the skills in assessing diabetic patients for risks of diabetic complications to facilitate early treatment and avoid morbidity.
In my future professional practice, I plan to assess every health educational material offered to patients to ensure that it is readable and understandable to all patients. Determining the readability of health materials will involve reviewing the language used to ensure that there is no medical jargon used and that medical terms have been explained in plain language (Wittink & Oosterhaven, 2018). I will also utilize readability assessment tools such as The Flesch-Kincaid readability tool to assess the readability score of each material and evaluating whether patients will understand based on their level of education (Wittink & Oosterhaven, 2018). I plan to integrate the skills in assessing readabiltiy into my professional practice when providing health education to patients to promote healthy behaviors and prevention of diseases.
A health care provider should assess a patient’s health literacy when providing health education to ensure that the patient can understand the education interventions. The patients’ education level significantly influences their ability to read and understand health education materials (Hersh, Salzman & Snyderman, 2015). During this course, I learned that a patient’s health literacy influences their health behaviors, including their lifestyle practices and disease prevention and control practices. Besides, health literacy levels affect an individual’s well-being, and people with low literacy levels are more likely to have poor health than those with high literacy levels (Wittink & Oosterhaven, 2018). On the other hand, patients with high literacy levels can understand health education provided to maintain health and prevent diseases, and this promotes healthy well-being.
References
Hersh, L., Salzman, B., & Snyderman, D. (2015). Health Literacy in Primary Care Practice. American family physician, 92(2).
Wittink, H., & Oosterhaven, J. (2018). Patient education and health literacy. Musculoskeletal Science and Practice, 38, 120-127.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
Advanced Heath Assessment Documentation Tutorial
In each of the Shadow Health (SH) Assignments, you will be asked to complete a narrative note as part of the grading criteria. Narrative or progress notes are often a new skill. This document is provided to assist students in understanding how to write a narrative note. Shadow Health refers to these notes as Provider Notes.
Documentation of patient care is essential to quality and safety of care. Much of the clinical documentation is completed electronically using point and click tools to describe the patient condition (Lindo, et al., 2016). Often computer prompts fall short of fully describing the patient condition. Other situations such as lack of technology, electrical outages, system hacking, failure of equipment, and any number of situations which may interfere with normal electronic documentation may require a narrative nurses/progress note. Nurses must be able to clearly communicate patient information with everyone on the health care team to ensure quality and safety of care (Lindo, et al., 2016).
Documentation must be clear, paint a picture of the patient, and provide measurable concise information in a timely manner. The information communicated must be able to be understood by others and provide enough information to understand if a change has occurred in the patient condition and to clearly communicate all treatments, interventions, and therapies received by the patient and/or planned for the patient. Documentation also serves as a legal record of care (Lippincott Williams and Wilkins, 2007).
Documentation begins with subjective data/information. This is information the patient, family member, or caregiver may provide if the patient is unable to communicate which includes such data as the history of present illness (HPI), the past history- allergies, medications, medical surgical & social and the review of systems (ROS). Objective data/information includes the physical exam, observations and measurements obtained during the examination of the patient. Objective data also includes vital signs, laboratory and diagnostic results (Bates, 2017, pg.7)
Subjective vs. Objective Data-As you begin to acquire data from the patient interview and physical exam, it is important to remember the difference between subjective and objective information. Symptoms are the subjective concerns of what the patient tells you of their experience. Signs are the objective findings from your observations. (Bates, 2017, pg.6). Sequence of data is documented in the manner it is collected from the sequence of the examination. Physical examination follows a cephalocaudal sequence with the cardinal techniques of inspection, palpation percussion and auscultation (Bates, 2018)
Subjective information assists in understanding the patient condition and provides a basis upon which the nurse decides which body systems need to be assessed and which assessments need to be completed. Many of the assessments to be performed in the class are focused or problem based and focus on the assessment of a specific body system. The Comprehensive assessment is a complete health history and physical exam of most all body systems (Bates, 2017. Pg.5)
Once subjective and objective information are obtained and have been thoroughly considered an assessment/nursing diagnosis or medical diagnosis (physicians and advanced practice only) is identified. A plan of care will then be developed based on the nursing diagnoses. In the health assessment competencies, the primary focus is on gathering accurate subjective and objective data (Bates, 2017, pg.24)
Subjective data should be recorded using the patient’s own words and describing his/her feelings and experiences related to health. When interviewing the patient about a current issue or illness the seven attributes of a symptom need to be included in the documentation (Bates, 2017, pg.79)). The seven attributes of a symptom would be asked for any positive response during the health history (HH) and review of systems (ROS). Here is a list of the attirbutes and a few sample questions for a patient with complains of abdominal pain (Bates, 2017, pg.79)
- Location: “Where does it hurt?” “Please point to the area of pain.”
- Quality: “How would you describe the pain?” “Is it sharp pain?” “Dull pain?”
- Quantity or Severity: “On a scale of 0-10, 0 being no pain and 10 being the worst pain ever, what is your level of pain?” “How has the pain impacted your daily routine?”
- Timing: “When does the pain occur?” “How long does it last?” “Approximately how long after you have eaten does the pain begin?” ”Does the pain radiate?” “If yes, where does it radiate?”
- Onset or Setting in which it occurs: “What were you doing when the pain began?”
- Aggravating or Relieving Factors: “Is the pain worse after eating certain foods?” “What makes the pain better?”
- Associated Factors: “Do you have any nausea or vomiting?” “Any diarrhea?” “Any constipation?”
Another way to remember what to ask the patient is to use the mnemonic OLDCARTS or OPQRST (Bates, 2017. p.79)
O: Onset
L: Location
D: Duration of symptoms
C: Character
A: Aggravating/Alleviating Factors
R: Radiation
T: Timing
S: Severity
OR
O: Onset
P: Provocative or Palliative
Q: Quality or Quantity
R: Region or Radiation
S: Site
T: Timing
When documenting the ROS it is necessary to document each condition or item asked about because others will be reading the notes and relying on the information provided. If information is incomplete or inaccurate patient safety and quality of care may be affected. Documentation of pertinent negatives should be specifically described. Do not overgeneralize by using terms such as “WNL”, or neurologic exam negative” as this does not convey what exactly was assessed subjectively and/or objectively (Bates, 2018, p. 38)
ROS (Subjective) Documentation Example:
Review the following ROS areas and the associated documentation and note the quality of the information provided for each system.
- Skin: Denies any rashes or changes to skin
- Head: No problems with head or headaches.
- Ears: Positive for fullness feeling in bilateral ears for past 2 days, denies changes in hearing, pain in ears or any drainage.
- Eyes: No problems, says they are normal.
Skin and ears are documented correctly. The skin description relays what items were subjectively asked of the patient. The ears ROS also includes pertinent positive with further information and pertinent negatives.
Head and eyes are not documented correctly. There is not a description of the items subjectively asked and is an incomplete picture.
(Bates, 2017, pg. 32)
Assessment (Objective) Documentation Example:
Skin: Uniform in color, tan, warm, dry, intact. Turgor good, skin returns immediately when released. Scattered flat small macules on face around nose. On back of left shoulder 4mm, symmetrical, smooth borders, dark brown, evenly colored, slightly raised nevus, without tenderness or discharge. Well healed pale scar 3 cm right forearm. Left wrist approximately 1 cm area around the circumference of the wrist pruritic papules and vesicles with an erythematous base. Silver colored striae around lower outer quadrants of abdomen and hips.
- Head: Shape okay.
- Eyes: Eye color brown. brows, lids, and lashes symmetric, right brow ridge piercing with intact silver hoop, no redness, tenderness, or discharge; lacrimal ducts pink and open without discharge. Conjunctiva clear, sclera white, moist, and clear, no lesions or redness, no ptosis, lid lag, discharge or crusting. Snellen vision assessment 20/20 in each eye with corrective lenses. EOMs intact, no nystagmus, PERRLA
- Ears: TM with good cone of light, pearly gray appearance, canal clear of wax bilaterally, no edema or drainage present. Auditory acuity present bilaterally to whispered voice.
Skin is documented very complete and concise a picture of the patient is evolving and measurable assessment data is provided. Complete description of the rash on the left wrist provides a measurable concise picture. A mole was noted and documentation included the ABCDE of the mole. It is important to describe both normal and abnormal findings in a measurable manner. The text offers examples of how to provide measurable information for many assessment findings such as tonsils, pulses, reflexes, and strength (Bates, 2017, pg. 33)
The documentation for head is less measurable. How is one to know what “shape okay” is for this patient?
The documentation for the eyes is very thorough and concise. Measurable terms are used and a description of the patient’s eyes is provided.
The documentation for the ears is also very concise and thorough. Measurable terminology is used and a description is provided.
Some of the Shadow Health (SH) exams focus on one body system such as Cardiac. In this situation focus on pertinent questions related to the ROS and physical assessment for cardiac and any associated body systems. In the case of cardiac, peripheral vascular and respiratory would be additional systems to assess.
When completing the assessments in SH use the textbook as a guide. Open to the appropriate chapter and follow along to ensure all aspects of the assessment are covered for both subjective and objective assessment areas. Document carefully for each assessment area keeping in mind the differences between subjective and objective information and ensuring measurable concise information is recorded.
Subjective and objective information is separated and each body system is used as a heading for easier retrieval of information. When information is disorganized it is difficult to know which is the information provided by the patient and which is the objective clinical assessment data. In an emergency retrieval of information must be done quickly. Well organized and written notes allow for timely retrieval (Lindo et al., 2016).
References
Bickley, L. S. (2017). Bates Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins: Philadelphia, PA.
Lindo, J., Stennett, R., Stephenson-Wilson, K., Barrett, K.A., Bunnaman, D., Anderson-Johnson, P., Waugh-Brown, V., and Wint, Y. (2016). An audit of nursing documentation at three public hospitals in Jamaica. Journal of Nursing Scholarship, 48(5), 508-516.
Lippincott Williams & Wilkins (2007). Charting: An incredibly easy pocket guide. Ambler, PA: Author.